The System exChange
The System exChange provides powerful tips and ideas for transforming your local community.
What is a Root Cause Analysis?
Are there certain problems in your community that people just can’t seem to solve - even though you've been trying for years? 

Do some local problems keep coming back again and again, regardless of what efforts are taken to solve them?

If yes, you’re not alone. Community problems can be difficult to solve - especially when local efforts only tackle the symptoms of those problems instead of what’s driving them.

A root cause analysis is a process of asking questions to understand why a problem is happening. Efforts that target these underlying “root causes” are more effective at solving problems (Stroh, 2015).
There are lots of ways to do a root cause analysis - the following is one approach adapted from CADCA :

On what kinds of problems can you use a Root Cause Analysis?
Root cause analysis can be used with any type of problem, including: 

  • Population-level problems (e.g., obesity rates, homelessness, high school graduation rates)

  • Social determinants of health (e.g. limited access to healthy food, lack of affordable housing, limited transportation options, neighborhood crime)

  • System or organizational problems (e.g. lack of coordination, low employee morale)

  • Implementation barriers (e.g., strategies not being used effectively, limited resident engagement in local efforts)
Where can you use a Root Cause Analysis process? 

Almost anywhere! Below are some examples of common opportunities to use root cause analysis:
Meetings: staff meetings, collaborative meetings
Services: interactions with clients or consumers
Planning: Strategic planning processes, program development, grant writing, other planning sessions
Conversations : anytime a problem comes up in conversation

Remember ! Because most problems have multiple causes, it's almost impossible for any single perspective to fully understand all the reasons why a problem is happening. You can help reveal the multiple root causes of a problem by engaging individuals representing different perspectives in your root cause analysis.
Check out this handy cheat sheet outlining the four-step Root Cause Analysis process.
Check out this short video on how to use a root cause analysis process to enhance your efforts.

Powerful Practices: 
Bringing a Systemic Lens into Root Cause Analysis 
Root cause analysis is a great way to understand why problems are happening. However, in our experience the root cause analysis process is often incomplete .

People often “forget” some important causes during this process and rely only on what first comes to mind. This is problematic because it can reinforce the status quo and promote “victim blaming” where individuals - particularly residents - are blamed for problems instead of focusing on system or structural causes.

How can you prevent this? Bring a "systems approach” into your root cause analysis process by helping stakeholders identify systemic root causes. The image to the right shows 6 common system conditions you could explore in your root cause analysis process.
Check out this tool for bringing a systemic lens into your root cause analysis process.
Check out this short video on how to bring a systems approach into your root cause analysis.

Practical Tips:
Get Specific
How can you ensure your root cause analysis gets you actionable issues that people can start addressing immediately? Get detailed! .

The easiest way to do this is by asking follow-up questions like:
  • What does this issue look like?
  • Who is involved?
  • Where is it happening?
  • When is it happening?
  • Can you give me an example?

TIP : Try to get enough detail so someone who wasn't part of your root cause analysis conversation would have enough information to take action on the issues.

The table below gives some examples of vague root causes (not very actionable) and more detailed root causes that are ready for action.

Vague Root Causes
(not actionable) 
Detailed Root Causes
No resident voice
Leaders and staff within local cross-sector organizations lack the skills to effectively gather and use resident input to guide their decision-making.
Policies get in the way of communication
Local cross-sector organizations' current interpretation and application of HIPAA policies prevent their staff from sharing critical information about shared clients.
Bad intake process
The intake processes to access local substance use supports requires consumers to go through 5 separate steps; the complexity and time it takes to complete these steps discourages people from finishing the intake process.

Q & A

Q: We'd like to engage more residents in our root cause analysis process...but aren't sure where to begin. What do you recommend?

A: Here are a few ideas you could try. Have people who have direct interactions with residents experiencing your targeted problems/inequities (e.g., home visitors, social workers, hair stylists) ask your root cause questions at the end of service visits or in the waiting room, and then send you what they learn. Or, identify existing meetings or gatherings where your priority residents naturally go during the week (e.g., church services, support groups) and see if the leaders of these groups can ask your root cause questions with residents and send you what they learn.

Submit your questions on the Contact Us page of the the MICHIRLearning website .
If you find this publication useful, forward to your colleagues and encourage them to subscribe !

Want access to more information about community transformation? Check out the Michigan CHIR Learning website !! This website includes information, tools, and resources to help support local collaborative efforts.

January 2020
Have an idea for a future System exChange? Email us at:
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Martin, J., McCormack, B., Fitzsimons, D., & Spirig, R. (2014). The importance of inspiring a shared vision. International Practice Development Journal, 4(2).

ORS Impact & Spark Policy Institute (2018). When Collective Impact has an Impact. Retrieved from 

Woolf, S. H. (2017). Progress in achieving health equity requires attention to root causes. Health Affairs, 36(6), 984-991.